Endocrinologist Annual Evaluation Checklist

Endocrinologist Annual Evaluation Checklist

Federal Diabetes Exemption Program

Driver Identifying Information

Name: __________________________________________________________________

First

MI

Last

Address: ________________________________________________________________

DOB (MM/DD/YYYY): ______________________

This applicant was granted an exemption from the Federal diabetes standard to operate a commercial motor vehicle (CMV) in interstate commerce. ANNUAL medical monitoring and reporting is a condition of the exemption from the diabetes standard of 49 CFR 391.41(b)(3).

PLEASE CHECK / FILL IN REQUESTED INFORMATION.

1. I am board-certified in endocrinology.

I am board-eligible in endocrinology.

If neither, do not continue your assessment. Applicants must be evaluated by an endocrinologist who is board-certified or board-eligible.

2. Office telephone number: ___________________________

3. Office fax number: ________________________________

4. Date of examination (MM/DD/YYYY): ______________________________

5. I have reviewed the patient's daily glucose logs (from his/her glucose monitoring device).

YES

NO

6. I have compared monitoring dates to his/her driving log to ensure that the individual is

checking glucose levels prior to operating a CMV as required.

YES

NO

If NO, please comment: __________________________________________________

7. I certify that this individual's glucose levels have been maintained in the range of 100 to 400

mg/dl while driving a CMV.

YES

NO

N/A

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8. I certify that this individual continues to maintain a stable insulin regimen and that his/her

glycosylated hemoglobin (A1C) result continues to reflect stable control of his/her insulin-

treated diabetes mellitus (ITDM).

YES

NO

9. FMCSA defines a severe hypoglycemic reaction as one that results in: Seizure, or loss of consciousness, or Requiring assistance of another person, or Period of impaired cognitive function that occurred without warning.

In the last 12 months, while being treated for diabetes, has the patient had a severe

hypoglycemic episode?

YES

NO

If yes, provide information on each hypoglycemic episode: Date(s): ________________________________________________________________________

Include additional information about each episode including symptoms of hypoglycemic reaction, treatment, and suspected cause: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Was the patient hospitalized?

YES

NO

If yes, provide brief summary of hospitalization: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

Has the patient's treatment regimen changed since the last hypoglycemic episode?

YES

NO

Briefly explain changes: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

10. Has the patient continued to receive education in the management of diabetes that includes

diet, monitoring, recognition and treatment of hypoglycemia and hyperglycemia?

YES

NO

If yes, please provide last education date (MM/YYYY): _______________

Note: The applicant must participate in a diabetes education program at least annually to remain in the diabetes exemption program.

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11. I hereby certify that in my medical opinion, this applicant understands how to individually

manage and monitor his/her diabetes mellitus. YES

NO

12. Please describe the progression in diabetes complications/end organ diseases that have occurred in the past year: (if none, write none)

a) Renal disease ____________________________________________________________ ________________________________________________________________________

b) Cardiovascular disease ____________________________________________________ ________________________________________________________________________

c) Neurological disease ______________________________________________________ ________________________________________________________________________

Autonomic neuropathy YES NO

(i.e, cardiovascular GI, GU)

Peripheral Neuropathy

YES NO (If YES, circle below) Sensory Decreased sensation Loss of vibratory sense Loss of position sense

13. Has the patient developed any of the following complications within the past year (please check yes or no):

Renal Disease Cardiovascular Disease

Neurological Disease

Renal insufficiency

Proteinuria

Nephrotic Syndrome

Coronary artery disease

Hypertension

Transient ischemic attack

Stroke

Peripheral vascular disease Autonomic neuropathy (i.e, cardiovascular GI,

GU)

Peripheral Neuropathy (Circle below) Sensory

Decreased sensation Loss of vibratory sense Loss of position sense

YES YES YES YES YES YES YES YES

YES

YES

NO

NO

NO

NO

NO

NO

NO

NO

NO

NO

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Comments: ___________________________________________________________________________ ___________________________________________________________________________

14. List all medications including those taken related to the treatment of diabetes (if none, write none):

Name of Medication

Dose

Reason for Taking the Medication

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

15. In your medical opinion, does any one of the listed medications have the potential to

compromise the driver's ability to operate a CMV safely?

YES

NO

If yes, which medication(s): ____________________________________________

___________________________________________________________________

16. In my medical opinion, the applicant has demonstrated the ability and willingness to

properly monitor and manage their diabetes. YES

NO

17. I hereby certify that in my medical opinion, the applicant is able to use insulin while safely

operating a commercial motor vehicle (large truck or motor coach) in interstate commerce

while using insulin.

YES

NO

18. Please attach a copy of your office letterhead with your printed/typed name, signature, date, medical license number, and state of issue to this checklist.

Please send this completed annual endocrinology checklist to:

Diabetes Exemption Program

1200 New Jersey Ave., SE

Room W64-224

Washington, DC 20590

If you have questions or need additional information, please call (703) 448-3094.

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Vision Annual Evaluation Checklist

Federal Diabetes Exemption Program

Driver Identifying Information

Name: __________________________________________________________________

First

MI

Last

Address: ________________________________________________________________

DOB (MM/DD/YYYY): ______/______/____________

This individual was granted an exemption from the Federal diabetes standard to operate a commercial motor vehicle (CMV) in interstate commerce. Annual medical monitoring and reporting is a condition of the exemption from the diabetes standard of 49 CFR 391.41(b)(3). An applicant with diabetic retinopathy must be evaluated by an ophthalmologist. The vision examination must occur AFTER any eye surgery/procedures (postoperatively).

PLEASE CHECK / FILL IN REQUESTED INFORMATION.

1. I am an ophthalmologist

I am an optometrist

2. Date of most recent examination: ______/______/____________

3. Distant visual acuity (please provide both if applicable):

UNCORRECTED

CORRECTED

Glasses

Contact Lens

Right eye: Left eye:

20/_____ 20/_____

20/_____ 20/_____

4. Field of vision (FOV)*: Please record the interpreted results in degrees of horizontal field of vision for each eye. The terms "normal" or "full" are not acceptable responses.

Right eye: ___________degrees Left eye: ___________degrees Test used to determine: _________________________________________

*Note: If the patient has received laser treatment, and in your medical opinion you believe the patient's FOV is compromised, FMCSA recommends formal perimetry to determine if the driver meets the FOV standard.

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